Agency for Healthcare Research and Quality, Rockville, Maryland.
Correspondence: Richard Kronick, PhD, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850 ( Director@ahrq.hhs.gov).
The author declares no conflicts of interest.
This commentary on patient safety in nursing practice comes from the Agency for Healthcare Research and Quality.
MANY ASPECTS of the US health care system are in flux, but one thing has not changed: nurses remain at the forefront of clinical care. Every day, nurses confront complicated patient situations, combining sophisticated technology and old-fashioned physical assessment skills to monitor and improve health. Nurses are central to the provision of evidence-based, patient-centered care.
Despite new evidence and advanced technology, many longstanding issues remain. Patient safety is one. While American health care sometimes is the best in the world, it is not always so. The quality of the care we provide is still uneven. Patients are still at risk of harm resulting from the care they receive. We still grapple with issues related to access and quality, and disparities with regard to race and ethnicity, gender, geography, and other factors. The problems that lead to these conclusions are persistent and have been rigorously documented.1
The Affordable Care Act directly addresses some of the underlying sources of these challenges. It extends health insurance coverage to millions of Americans, rewards higher quality, and reforms the rules for health insurance sold to individuals. American patients and the system that serves them will benefit from these changes. There have been some growing pains, but there also is little doubt that we are advancing inexorably toward a better future.
As the Agency for Healthcare Research and Quality's (AHRQ) new director, it is my goal to help the Agency navigate this future direction for health care and contribute to its success.
Understanding our system and working to promote the application of proven advances in care are 2 ways that AHRQ can contribute to improving it. I believe nurses, particularly those of you with a vested interest in improving the quality of care within your organizations, will continue to help lead the quality improvement (QI) movement. AHRQ produces evidence that can be used to make health care safer, higher quality, more accessible, equitable, and affordable, and works with the US Department of Health and Human Services and other partners to make sure that the evidence is understood and used. Many things indeed have changed in recent years, but one thing has not: AHRQ's commitment to advancing the science to improve the quality of care for all Americans. More than ever before, we are depending on nurses to help us fulfill this mission.
TOP PRIORITY FOR ACTION: IMPROVING PATIENT SAFETY
AHRQ is focusing on several priorities to achieve its mission. One in particular merits special mention: producing evidence to make care safer and fostering the use of that evidence.
Patient safety is a topic with which the Agency is intimately familiar. We have come a long way, but the evidence is clear that we have a great deal of work ahead of us to make US health care as safe as it can be. It is estimated that 1 in 7 hospital patients experiences preventable harm in the course of a normal health care experience. This is unacceptable and a chief reason why patient safety remains a core priority for AHRQ. It is the Agency within the Department of Health and Human Services specifically tasked with providing evidence on how to make patient care safer.2
The Agency's patient safety research investigates the ways patients are harmed, why this harm occurs, and how to prevent it. It translates the results of this research into practical tools and implementation approaches for providers to use in making health care safer. As a Nation, we have learned a lot about how to make care safer from the research that AHRQ has funded in the last decade and a half. We intend to continue this role and have 5 immediate goals for this priority:
- Preventing health care–associated infections (HAIs)
- Accelerating patient safety improvement in hospitals
- Reducing harm associated with obstetrical care in labor and delivery
- Improving safety and reducing medical liability
- Accelerating patient safety improvement in nursing homes
These priorities directly support the National Strategy for Quality Improvement in Health Care (National Quality Strategy), a nationwide effort to align public and private interests to improve the quality of health and health care for all Americans,3 and other national efforts to make care safer. By making this a priority Agency-wide, we reinforce AHRQ's role as the Nation's primary source for patient safety research. Researchers and planners are busily working on new projects or expanding existing strategies and products that will add to the evidence base in patient safety and offer tools that will make our system safer for American patients. In the meantime, I would like to share with you existing products and work that AHRQ has done that may be used today to improve safety.
HAIs are well known as a major patient safety challenge, and HAI prevention is an area in which the Agency's work has already had a substantial impact. A major element of AHRQ's HAI work is the Comprehensive Unit-based Safety Program (CUSP). Regular readers of this journal are likely familiar with CUSP,4 a customizable program that helps hospital units address the foundation of how clinical teams care for patients. This program, which is often a nurse-led intervention, combines a checklist of clinical best practices with an understanding of the science of safety, improved safety culture, and an increased focus on teamwork and communication. A video of how CUSP can be implemented from a nurse's perspective is available at www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/00_nurse/.
The Agency's nationwide project to promote the use of CUSP achieved a 41% reduction in central line-associated bloodstream infections (CLABSIs) in more than 1000 intensive care units (ICUs) across the country and a 58% reduction in CLABSIs in 100 hospital neonatal ICUs in 9 states.5,6 Building on this success, AHRQ's nationwide project of CUSP for catheter-associated urinary tract infections has so far led to an approximately 19% reduction in these infections, although these are preliminary numbers at about the midpoint of the project. To help clinicians implement CUSP, AHRQ has developed a CUSP toolkit, which includes training tools to help physicians, nurses, and other clinical team members learn how to work together more effectively and efficiently to make care safer for patients. More information about the CUSP toolkit can be found at www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html.
Patient safety improvement in hospitals
The hospital setting has been the initial focus of work for many QI efforts and remains a key clinical interest. One area in which AHRQ is heavily engaged is improving patient safety culture within hospitals—starting with measuring the culture with the Hospital Survey on Patient Safety Culture,7 a staff survey designed to help hospitals assess the culture of safety in their institutions. Hundreds of hospitals across the Nation and internationally have implemented the survey. Other resources include guides to help hospitals handle patients with limited English proficiency8 and to help patients, families, and health professionals work together as partners to promote improvements in care.9
Reduce harm associated with obstetrical care in labor and delivery
This is a relatively new area of specific focus for AHRQ, but it is an area of great need. It is estimated that obstetrical adverse events, including perineal tears, hemorrhaging, maternal death, and injuries to the skeleton or spinal cord of the infant, occur in approximately 9% of all US deliveries.10 There is evidence that safety programs in labor and delivery units can improve workforce perceptions of safety and an improved safety climate.11 AHRQ has already developed patient safety indicators ( www.qualityindicators.ahrq.gov/modules/psi_overview.aspx) dealing with obstetrics, has funded additional work in this area as well,12 and, as mentioned earlier, has applied CUSP to the neonatal ICU setting with impressive results.13 A perinatal safety project is in the works, and we expect to devote additional resources toward improving patient safety in this important area in the very near future.
Improve safety and reduce medical liability
When a patient is injured, the problem is not always resolved to his or her satisfaction. Patient harm due to negligence is a safety issue. Patient harm should never happen, but when it does, the system should be able to do 2 things: serve the patient's needs and learn from the experience to promote patient safety and higher quality care.
Thanks to AHRQ-funded research, we know that better communication between providers and patients and guidance on resolving issues can increase patient satisfaction and improve safety. AHRQ is now funding research to develop a toolkit for hospitals that supports better communication and assistance with resolving potential legal issues when patients are unexpectedly harmed by the care they receive.
Patient safety improvement in nursing homes
Much like hospitals, the nursing home setting has been the focus of many QI programs. And, like hospitals, AHRQ is applying and tailoring strategies that have been proven to work in hospitals into nursing homes. Examples include:
- TeamSTEPPS. A teamwork system designed for health care professionals and developed by AHRQ and the Department of Defense, TeamSTEPPS is a multistep process designed to create and sustain a culture of safety. The long-term care version of TeamSTEPPS adapts the core concepts of the program to reflect the environment of nursing homes and other long-term care settings.14
- Patient safety culture survey. As was demonstrated in hospitals, a culture of safety underlies error-free care. Thus, AHRQ has developed the Nursing Home Survey on Patient Safety Culture.15
- CUSP in long-term care facilities. Building on the success of CUSP in hospitals, AHRQ is funding a project to implement the safety program in nursing homes nationwide with a specific emphasis on preventing HAIs such as catheter-associated urinary tract infections.16
CONCLUSION: HEALTH SERVICES RESEARCH AND YOU
AHRQ has long recognized the integral role that nurses play in the health care quality enterprise. Nurses are essential members and leaders of the health care team. Previously published AHRQ work17 has recognized that nurses are at the center of patient care and therefore are central drivers of QI.
As a Nation, we depend on nurses to improve health care quality. Nurses have valuable insight on how to navigate the health care system for safe handoffs, interpret information, engage patients and families, and demystify the clinical experience for patients. Nurses are pivotal in ensuring that patients receive safe, high-quality, evidence-based health care.
As we move forward in developing our patient safety portfolio, AHRQ has numerous opportunities for nurses. Nurses not only implement evidence, they advance and create it as scientists as well. Thus, there are opportunities to develop new knowledge and apply available research and tools to improve practice through large and small research grants. We also have a great deal of research that nurses can incorporate into their practice and use to bolster nurses' central role in patient safety. To learn more about these opportunities and about the Agency, please visit our Web site, www.ahrq.gov, and specifically our funding opportunities Web site, www.ahrq.gov/funding/fund-opps/index.html.
4. Clancy CM. Getting to zero: our effort to eliminate infections nationwide. J Nurs Care Qual. 2010; 25:(3):189–192.
11. Pettker CM, Thung SF, Raab CA. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet Gynecol. 2011; 204:(3):216.e1–216.e6.
12. Nicholson WK, Wilson LM, Witcop CT, et al. Therapeutic Management, Delivery, and Postpartum Risk Assessment and Screening in Gestational Diabetes. (Evidence Report/Technology Assessment No. 162). Rockville MD: Agency for Healthcare Research and Quality; 2008. www.ncbi.nlm.nih.gov/books/NBK27011/
. Accessed April 8, 2014.
16. HRET awarded new contract from AHRQ to reduce infections in long-term care facilities and improve patient safety. News release from the Health Research and Educational Trust, Chicago, IL. December 3, 2013 .
17. Hughes RG., ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008 .